Building Foundations eHealth

Building
FOUNDATIONS
eHealth
in Europe
Report of the WHO Global Observatory for eHealth

B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E GOe
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G l o b a l o b s e r v a t o r y f o r e h e a l t h
Report of the WHO Global Observatory for eHealth
in Europe
Building
FOUNDATIONS
eHealth for

B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E GOe
Acknowledgements
Sincere thanks are due to more than 100 eHealth experts throughout the European Region who helped
shape this report by sharing their knowledge through completing the first global survey on eHealth.
Further, the undertaking of the survey required considerable coordination at the regional and national
levels. WHO regional coordinators for Europe played a vital role in this process. Additionally, staff at WHO
headquarters and external specialists provided support in the design of the survey instrument as well as
technical input in their areas of expertise. Thanks are due to:
Can Celik, Somnath Chatterji, Joan Dzenowagis, Steeve Ebener, Maribel Gene, Bernhard Gibis, May-Brit
Hansen, Jean-Claude Healy, Misha Kay, Kaarina Klint, Yunkap Kwankam, Itziar Larizgoitia-Jauregui, Doris
Ma Fat, Maryo Olesen-Gratama van Andel, Oana Roman, Gerard Schmets, Tevfik Bedirhan Üstün.
This report was prepared by the World Health Organization’s Global Observatory for eHealth, European Region by:
Angela Dunbar (secretariat), Misha Kay (secretariat), Kaarina Klint (consultant), Kai Lashley (editor), Jillian
Reichenbach Ott (design and web publishing), Niels Rossing (consultant) and Rudi Samoszynski (consultant).
Photo credits:
Shutterstock

GOe
Contents
Executive summary vii
Findings at a glance 1
The Global Observatory for eHealth 5
GOe operational framework 6
Overall goals 7
The first global survey on eHealth: perspectives from
the European Region 9
Purpose 9
Reporting results 9
Survey in brief 9
Respondents 10
Response rate 11
Discussion of the findings 15
Introduction 15
Foundation policies and strategies 16
Governance 16
Policy framework 18
Funding approaches 22
Infrastructure 26
Enabling policies and strategies 29
Citizen protection 29
Equity 31
Multilingualism and cultural diversity 33
Interoperability 37
Capacity building 41
eHealth applications 44
Public services 44
Knowledge services 46
eLearning in health sciences 50
Provision of tools and services 52
References 55
Annex 57
Explanatory notes 58
Country profiles 60
Summary Findings GOe Survey Discussion References Annex
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vi GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E

GOe vii
Executive summary
Efficient high-quality health care delivery depends on well-designed health systems. Effective use of
technology for health can achieve these goals through streamlining processes as well as offering entirely
new ways of working. eHealth provides tools and solutions to improve health systems and services,
such as respecting the rights of the patient (giving them more information about, and increased control
over their health choices) and utilizing efficiently human, financial and other resources (1).
WHO defines eHealth broadly as the use of information and communication technologies for health.
Although many definitions exist, there is wide agreement on a core principle: eHealth represents a
commitment for networked, global thinking, to improve health care locally, regionally, and worldwide
by using information and communication technology (2).
The impact of eHealth is far-reaching and diverse. It includes health-information web sites, access to
secure patient data, telemedicine and communications technologies, health institutional administration,
decision support, cost savings and much more. It is not simply about technology, but about people
working together; it is not a goal in itself, but a set of tools or means to reach defined ends; finally,
eHealth is about the access to, and transfer of knowledge, not just about data collection.
eHealth can support diverse functions of the health system, such as strengthening its information,
intelligence and knowledge processes such as through integrated hospital information systems
and electronic health records. It should be an essential component of any health system reform
or development plans and strategies. It is increasingly becoming an integral element of national
health system objectives, and is becoming recognized as a key enabler in improving the quality and
efficiency of public health services globally.
In 2005 the World Health Organization (WHO) Global Observatory for eHealth (GOe) coordinated
the first ever global survey on eHealth, the results and findings of which are available in the
publication Building foundations for eHealth: progress of Member States (3). Complementing
the global publication, this report offers a more detailed analysis of the findings of the survey
specifically how they relate to the WHO European Region.
This report is an essential survey-based tool for presenting an overview of eHealth uptake in
the European Region. Its overall aim is to further WHO’s eHealth strategy of strengthening
health systems; capacity building, developing norms and standards and fostering public-private
partnerships as part of the overall framework for action detailed in the resolution on eHealth by
the World Health Assembly (WHA) in May 2005 (4).
Given the GOe eHealth survey was the first of its kind, the Observatory was greatly encouraged by the
number of Member States that responded – 112 countries, 26 of which were from the European Region
(50% of Member States in Europe, representing approximately 64% of the Region’s population).
Although this first survey provides important insight into eHealth uptake across the Region, further
and deeper evidence into eHealth strategy effectiveness and efficiency is required. The Observatory is
committed to work with Member States to generate and disseminate relevant, timely, and high-quality
evidence and information to support national governments and international bodies in improving
policy, practice and management of eHealth.
The WHO European Region comprised 52 countries at the time of survey closure (mid-August 2006).
Contents Summary
Findings GOe Survey Discussion References Annex

viii GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E

GOe
Findings at a glance
Strong political will for eHealth across the European Region
Evident in the findings of the survey is the political will behind the advancements of eHealth across the
WHO European Region. There is a strong trend of policy adoption for all of the foundation, enabling and
application action areas queried in the survey.
Inherent in this policy adoption is the certainty that information and communication technologies (ICT)
are being seen as essential components of an integrated and well-functioning health-care system. Health
authorities are increasingly incorporating information-based, virtual networks of health professionals,
goods and services driven by the needs of their citizens, alongside the building of health facilities.
eHealth leapfrogging
Developing countries in the European Region are skipping over some of the eHealth activities
that other, more developed countries struggled with in the 1980s and 1990s. Rather than trying to
adapt their health systems to new technologies through entrenched ways of doing things, these
countries can start ‘fresh’ with the technology of today. For example, countries currently building
their ICT networks have not had to modernize their telecommunication and optic fibre systems to
accommodate newer ways to transfer information. Wireless technology has made that unnecessary,
and countries simply begin with this and move forward.
Survey findings from the European Region are in contrast to the findings from the global perspective
in several ways. A consistent relationship was less evident across the Region between World Bank
income groups and the introduction of eHealth actions by countries, for example. Further, in many
cases countries in the upper-middle income group were found to be rapidly advancing in their eHealth
development patterns relative to those in the high-income group. These countries, primarily made up of
the new European Union (EU) Member States, illustrated a greater adoption rate of eHealth foundation-related
policies including national information policies, ePolicies and eHealth-specific policies. They
also had higher rates of adoption of standards, ICT affordability and translation and cultural adaptation
policies. They illustrated remarkably higher access rates for knowledge services including online access
to international and national journals and access to open archives. Finally, they appeared to be more
inclined to provide ICT training for health sciences students, demonstrating, overall, an eagerness to
adopt new health provision mechanisms using the domain of eHealth.
World Bank income groups are based on World Bank estimates of 2004 Gross National Income (GNI) per capita: (1) high income, US$ 10
066 or more; (2) upper-middle income US$ 3 256–US$ 10 065; (3) lower-middle income, US$ 826–US$ 3 255; and (4) low income, US$ 825
or less. These were the latest available data as at the time of analysis for Building foundations for eHealth: progress of Member States (3).
Ten EU Member States with Year of EU entry: 2004, and 2 EU Member States with Year of EU entry: 2007. For more details, see http://
europa.eu/abc/european_countries/eu_members/index_en.htm.
Summary Findings
Contents GOe Survey Discussion References Annex

Solid progress made in implementing foundation actions
The European Region as a whole has a higher rate of established national eHealth task forces than the
global average, which places the Region in a good position to govern eHealth uptake, develop and
implement eHealth policies, infrastructures and services. This is important because a lack of national
eHealth task forces often leads to fragmented governance.
Similarly, the Region has a high rate of policy adoption compared to the global average for all three
forms of policy queried (national information policy; national ePolicy; and national eHealth policy).
Public funding continues to be the most common source of financing for ICT in the health
sector in the European Region. The importance of evidence-based eHealth project successes
and examples of proven practices to assist ministries in their search for scarce funding resources
should be articulated and encouraged.
The highest proportion of private funding is found among the lower-middle income group, which is
opposite of what is found globally. The lower-middle income groups likely received substantial funding
from development banks and agencies as well as the EU itself. Although private funding is utilized
extensively in the Region, the rate of public-private partnerships is not; it is lower than the global
average, as is the adoption and use of procurement policies.
Implementation of enabling actions needs attention
Enabling policies and strategies help citizens benefit from eHealth. This is the area of policy which is not
well developed in the European Region. It will require concerted actions by governments to assure citizens
that their (electronic) information is secure, incorporate multilingual and culturally diverse projects, adopt
standards and interoperability measures and ensure greater equity in the provision of eHealth services.
To avoid the possibility of abuse of patient data through the misuse of technology, it is critical that
citizen protection policies are introduced and enforced. Although the European Region currently has
a higher than global average in citizen protection policies overall, only 70% of countries in the upper-middle
and 33% of those in the lower-middle income group have implemented standards, regulations
E P or legislation to protect the privacy and security of patient data.
EURO IN h t l a e h e r o f s n o i t a d n u o F g n i d l i u B GOe Contents Summary Findings GOe Survey Discussion References Annex
For eHealth services to be accessible to all, equity and multilingual measures need to be in place.
Currently, only half of the respondents in the upper-middle category have equity policies and not one
from the lower-middle group does. Multilingualism and cultural diversity is the least developed area of
eHealth surveyed. Special attention is needed to promote the necessary policies and related projects
which directly affect citizen access to information so as not to exclude them from health information
services based on language barriers.
eHealth services can only fully function through actual and sustainable interoperability within and
between health systems. The European Region shows a much higher overall percentage of countries
adopting norms and standards for eHealth systems, services and/or applications than the global
average. At the time of the survey, all responding countries stated they would have adopted standards
for eHealth by 2008, Future surveys may well show this to be the case.
eHealth services can only be used effectively and efficiently if the health professionals using them have
been given adequate training. The lack of ICT-literate health professionals is one of the most frequently cited
problems by responding Member States and is a significant barrier to eHealth implementation at all levels.
Findings

GOe
eHealth applications for the citizen
eHealth applications are those provider services, knowledge services and public services that directly impact
the citizen. The range of eHealth applications is extensive and only a small subset was addressed in this survey.
Providing health information online to the public has significant potential to increase access to health
services. The European Region is relatively advanced in making efforts to enhance the accessibility,
quality and reliability of health information content.
As far as providing online international health sciences journals to students, researchers and practitioners,
the European Region shows a higher rate of these specialist services than the global average. Effort
is still needed, however, in making national electronic journals more accessible within countries and
internationally, as well as creating national open archives for health publications and data.
eLearning in the health sciences has grown rapidly in recent years though the lag in the lower-middle income
countries is considerable. Member States are urged to incorporate eLearning methods, where appropriate,
into their training of health sciences students as well as for the ongoing training of health professionals.
European Member States were also surveyed to assess which WHO provided eHealth tools and services
could offer the most benefit to them. Responding Member States would welcome active involvement
of WHO to provide services in the areas of effective/best eHealth practices, trends and developments
in eHealth, as well as advice on methods for monitoring and evaluation of eHealth services. Additionally
they indicated that (in principal) the following generic applications would be most useful: decision
support systems, national drug registries, national electronic registries and Telehealth.
Summary Findings
Contents GOe Survey Discussion References Annex

GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E

GOe
The Global Observatory
for eHealth
In May 2005, the Fifty-eighth World Health Assembly adopted Resolution WHA58.28 (4), which
established an eHealth strategy for the World Health Organization (WHO). The resolution urged Member
States to plan for appropriate eHealth services in their countries. That same year, WHO launched the
Global Observatory for eHealth (GOe), an initiative dedicated to the study of eHealth – its evolution and
impact on health in countries. The Observatory model combines WHO coordination both regionally
and at headquarters to monitor the development of eHealth worldwide, with an emphasis on individual
countries. WHO recognizes that eHealth is rapidly transforming the delivery of health services and
systems around the world, and is therefore playing a central role in shaping and monitoring its future,
especially in low- and middle-income countries.
The Observatory’s mission is to improve health by providing Member States with strategic information
and guidance on effective practices and standards in eHealth. Its objectives are to:
provide relevant, timely, and high-quality evidence and information to support national
governments and international bodies in improving policy, practice and management of eHealth;
increase commitment among governments and the private sector to invest in, promote and advance eHealth;
generate knowledge that will significantly contribute to the improvement of health through the use of ICT; and
disseminate research findings through publications on key eHealth research topics as a reference
for governments and policy-makers.
The Regional Office for Europe acts as a coordinating body for the Observatory’s work within the European Region.
Summary Findings Contents Survey Discussion References Annex
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GOe

GOe operational framework
Figure 1 illustrates the operational structure of the GOe. The GOe Secretariat was established in 2005.
The Strategic Advisory Group of Experts (SAGE) comprises experts from both the public and private
sectors and represents eHealth practitioners, researchers and policy-makers from across the globe. The
Secretariat is based at WHO headquarters in Geneva and works with the active input and support of its
regional counterparts in all six WHO regions.
National Observatory
Group
Strategic Advisory
Group of Experts
(SAGE)
E P EURO Thematic Working
Group
IN h t l a e h e r o f s n o i t a d n u o F g n i d l i u B GOe Contents Summary Findings Survey Discussion References Annex
Thematic Working
Group
Thematic Working
Group
Thematic Working
Group
Group
Group
Group
Group
Group
Group
Group
Secretariat
Strategic Group of (SAGE)
GOe groups Secretariat
Thematic Group
Groups
Figure 1. GOe operational framework
Thematic Working
Group
Working
Thematic Working
Group
Group
Observatory
Group
Group
Strategic Advisory
Group of Experts
(SAGE)
Group
Group
Secretariat
Strategic Advisory
Group of Experts
(SAGE)
GOe groups Target participants
Universities
Private sector (e.g. IT orgs)
Public sector
NGOs
Professional bodies (e.g. IMIA)
All WHO staff including:
- GOe
- Regional coordinators
- National coordinators
Thematic Working
Group
Groups
Experts in variety of areas
relevant to eHealth
Experts who have knowledge
of eHealth, dedication, and
influence at the national level
to achieve the GOe goals
Secretariat
GOe

GOe
Overall goals
The GOe is a global networked operation and its success is dependent on having access to information at the
national and local level in all Member States. The first global survey was successfully conducted in 2005/2006
– 700 expert informants from 112 Member States participated. In order to enhance the Observatory’s capacity
to deliver reliable and current information this network needs to be consolidated and expanded. Currently, the
Observatory is running a concerted campaign to recruit additional institutions to form National Observatory
Groups (NOGs) in each country. This will be mainly achieved through collaborating with international
professional associations in eHealth, medical informatics and telemedicine.
The National Observatory Groups will:
contribute to the development of the global survey instrument on eHealth;
assist with in-country data collection and analysis using methodologies and instruments developed
for use globally;
convene and mobilize national stakeholders (such as those in the health, technology,
telecommunications and education sectors) for data collection and analysis;
collect and analyse additional country-specific data (determined by the needs of individual
countries) in the context of the global eHealth survey;
monitor and report trends which impact eHealth policy and practice in specific countries;
promote the in-country use of findings from the GOe survey towards improved eHealth
policy and practice; and
provide information for other WHO-based eHealth initiatives on an ad hoc basis.
Thematic working groups are also being established in strategically important areas such as eHealth
policy; proven eHealth practices, equity of access and multilingualism; eLearning; and Telehealth. These
groups will evolve over time, and where possible, the GOe will collaborate with existing groups. In cases
where there are no groups in existence in a particular thematic area, the GOe will convene them and
seek suitable partners to carry them forward.
Summary Findings Contents GOe
Survey Discussion References Annex
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GOe
The first global survey
on eHealth: perspectives
from the European Region
Purpose
This report follows the recent worldwide eHealth survey, and the subsequent publication of the
Observatory’s survey report Building foundations for eHealth: progress of Member States (3). It focuses on
the information gathered from the European Region. The subsequent discussion will show this Region’s
current eHealth situation, which will enable countries to compare their progress against others using
identified regional and global statistical means as a benchmark. Through the use of such benchmarks,
policy-makers in European countries will be able to advocate for further development in specific eHealth
areas, thereby raising the standards of eHealth throughout the Region.
Reporting results
This report provides an analysis of the data from the participating countries from the European Region
that responded to the eHealth survey. All tables referring to trends used the data from the 25 countries
that responded by the time of survey closure (mid-August 2006). Calculations involving World Bank
income groups are based on 26 countries as the results from one further country, whose response
arrived after survey closure, could be incorporated in these later calculations. Areas of analysis include
policy development, funding environments, infrastructure, capacity, eHealth for citizens and access to
electronic information on the part of the public and health professionals. Full country data sets for all 26
countries, including country profiles, are available online.
A solid statistical complementary source of information to the GOe eHealth country profiles is provided
in Connecting for health: global vision, local insight (5). Produced by WHO for the WSIS, this publication
contains profiles of each Member State according to specific statistics on health, demographics and
ICT, which provide a context in which investment in ICT for health can be better understood by all
stakeholders.
Survey in brief
A detailed description of the first eHealth survey conducted by the Observatory can be found
elsewhere (3). The seven survey themes of the global report are reported here with a specific focus on,
and analysis of the WHO European Region. These themes are:
Enabling environment – policies and strategies
Infrastructure – access to ICT
Content – access to information and knowledge
Cultural and linguistic diversity, and cultural identity
Capacity – human resources knowledge and skills
National Centres for eHealth
eHealth systems and services – the needs of Member States
http://www.who.int/GOe.
http://www.itu.int/wsis/.
Summary Contents Findings Discussion References Annex
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2.
3.
4.
5.
6.
7.
GOe Survey

The methodology used for conducting the survey and the coordination between WHO Headquarters
and the European Region followed the procedures that were conducted globally. Of importance was
the liaison between the Regional office and WHO country offices and national counterparts. This is
because the country offices were closest to the informants and were usually involved in arrangements
for the focus groups. Several sections of the global eHealth survey report have been used here because
they are relevant to the discussion of the European Region.
Countries were asked to attribute a score for each eHealth action ranging from not effective to unknown
with the gradations in between of slightly, moderately, very and extremely effective. This rating system is
based on the “perceived effectiveness” by the group rather than on evidence. Reference to scientific
evaluation of programmes was not required. To simplify analysis and demonstrate trends more clearly,
it was decided to aggregate these scores in the reporting of the results into three broader groups: (i) not
and slightly effective; (ii) moderately effective; (iii) very and extremely effective.
The WHO Member States of the European Region have been grouped according to World Bank income
groups, within the context of opportunities for eHealth.
Respondents
The WHO European Region now comprises 53 countries with great geographical diversity and many
cultures, religions and languages. It is home to some 870 million people – close to one fifth of the
world’s population. GDP per capita varies enormously in the Region, from close to US$ 30 000 in Western
European countries to some hundreds in the Central Asian Republics. Health care expenditure per capita
increases manifold from the most eastern countries to those countries in the European Union. People
born in western Europe can expect to live on average 10 years longer than those born in eastern Europe.
Inter- and intra-country inequity in the Region is thus a serious issue. The economic differences run in
parallel with ICT penetration and contribute to the ‘digital divide’.
World Bank income group 1
Countries in the high-income group have long established health delivery systems which are hard
to change. Cross-border interoperability and change management are key problems to solve. These
countries have national or regionally derived resources to spend on ICT for health.
10 GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E Summary Findings Contents GOe Survey Discussion References Annex
These countries are generally not bound to legacy health delivery systems and can therefore adopt new
technologies more quickly. They are considered upper-middle income countries, and have a fair range of
resources to spend on ICT for health. eHealth activities in this group of countries tend to support projects
with national frameworks and are generally financed through international developmental organizations
and sustained through national funds. By making ICT an integrated element of newly developed health
delivery systems, countries can quickly expand (and improve) their health delivery services.
These countries are distinguished by their scarcity of resources. Referred to as lower-middle income
countries, their technological knowledge, however, is growing rapidly. For many the benefits of eHealth
have not yet materialized and the rather uncoordinated eHealth developments tend to be supported
projects financed and sustained through international developmental organizations with little national
involvement. This often leads to a lack of continuity or sense of ‘ownership’ over the system(s) in place.
World Bank income groups are based on World Bank estimates of 2004 Gross National Income (GNI) per capita: (1) high income, US$
10 066 or more; (2) upper-middle income US$ 3 256–US$ 10 065; (3) lower-middle income, US$ 826–US$ 3 255; and (4) low income, US$
825 or less. (For more information see: http://www.worldbank.org.)
Survey

GOe 11
None of the three countries in group 4, or low-income group, in the European Region responded
to the survey. Reasons for this stem from a lack of capacity – these countries did not have eHealth
professionals to respond to the survey. For consistency, this group has been included in the
analytical figures with zero responses.
Response rate
A total of 26 countries (50% of the 52 WHO European Region Member States, representing approximately
64% of the Region’s population) responded to the survey. Responses by Member States to the global
eHealth survey are the only data sources used as the basis for this report. Table 1 shows the distribution
of the responding countries by WHO World Bank income group and Table 2 is a list of all WHO European
Region Member States, by response to the survey and World Bank income group. At the time of the
survey closure (mid-August 2006) the WHO European Region comprised 52 countries. This number rose
to 53 on 29 August 2006 when Montenegro became a Member of WHO.
World Bank income group
European
Region
Member States
High income Upper-middle
income
Lower-middle
income Low income
Total no. of countries 52 25 11 13 3
No. of responding
countries 26a 13 10 3 0
Response rate % 50 52 91 23 0
a Calculations involving World Bank income groups are based on 26 countries as the results from one further country, whose response
arrived after survey closure, could be incorporated in these later calculations.
Table 1. Response rate to the eHealth survey, by World Bank income group
Almost all of the upper-middle-income level countries responded to the survey. This is in contrast
to a 50% response by this group globally. This should allow a relatively complete picture to emerge
for this group of countries, which can be used to better plan for eHealth programmes. Highlighting
common trends and needs of the European Region overall should also facilitate planning for future
development. Unfortunately, the countries in the low-income category did not respond to the survey,
so trend data for this group cannot be examined.
The responses of countries in both the lower-middle and lower-income groups (23% and 0%,
respectively) were lower than the global response rates (45% and 65%, respectively). The high-income
group response of 52% was on a par with the global response rate, which was 45%. As with the global
results for this group, some of the more developed countries may have found the survey relatively
elementary for their level of advancement in eHealth.
The WHO European Region comprised 52 countries at the time of survey closure (mid-August 2006).
Contents Summary Findings GOe Survey Survey
Discussion References Annex

12 GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E
Figure 2. Participating WHO European Region Member States
The designations employed and the presentation of the material in this publication do not imply the expression
of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© World Health Organization 2008.

GOe 13
Countrya
World Bank
categoryb Countrya
World Bank
categoryb
Albania 3 Latvia 2
Andorra 1 Lithuania 2
Armenia 3 Luxembourg 1
Austria 1 Malta 1
Azerbaijan 3 Monaco 1
Belarus 3 Netherlands 1
Belgium 1 Norway 1
Bosnia and Herzegovina 3 Poland 2
Bulgaria 3 Portugal 1
Croatia 2 Republic of Moldova 4
Cyprus 1 Romania 3
Czech Republic 2 Russian Federation 2
Denmark 1 San Marino 1
Estonia 2 Serbia and Montenegro 3
Finland 1 Slovakia 2
France* 1 Slovenia 1
Georgia 3 Spain 1
Germany 1 Sweden 1
Greece 1 Switzerland 1
Hungary 2 Tajikistan 4
Iceland 1
The Former Yugoslav Republic of
Macedonia 3
Ireland 1 Turkey 2
Israel 1 Turkmenistan 3
Italy 1 Ukraine 3
Kazakhstan 3 United Kingdom 1
Kyrgyzstan 4 Uzbekistan 4
Table 2. WHO European Member States by World Bank income group
a.
List of WHO European Member States at the time of survey closure (mid-August 2006).
b.
World Bank income groups are based on World Bank estimates of 2004 Gross National Income (GNI) per capita: (1) high
income, US$ 10 066 or more; (2) upper-middle income US$ 3 256–US$ 10 065; (3) lower-middle income, US$ 826–US$ 3 255;
and (4) low income, US$ 825 or less. These were the latest available data as at the time of analysis for Building foundations for
eHealth: progress of Member States (3).
* Not included in the general analysis.
Bold Indicates survey respondents.
Summary Findings Contents GOe SSuurvrveeyy Discussion References Annex

GOe 15
Discussion of the findings
Introduction
Because many European national health-care industries are publicly owned, the operational efficiency
of this sector can have a strong impact on the national budget. The use of ICT in the health-care sector
can streamline the administration of health-care organizations, improve delivery of clinical services and
increase the reach of public health education for its citizens.
The implementation of successful eHealth systems at the national level is dependent on a framework
of strategic plans and policies being put in place (creating a foundation of eHealth development). Such
e-strategies can unite rival and divergent views by involving all stakeholders in a common project
and focus energy and resources into key development objectives. These plans and policies should be
legislated in such a way as to enable eHealth applications and services which are useful, accessible,
private and confidential to all citizens, regardless of culture, language or location.
The eHealth Development Model (Figure 3) is a structured framework adapted by the Global Observatory
for eHealth, in which to consider and report the survey results.
Source: Building foundations for eHealth: progress of Member States (3).
Summary Findings Contents GOe Survey References Annex
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Figure 3. eHealth Development Model
Discussion

Foundation policies and strategies form the basis of national eHealth development. They deal
with infrastructure, funding, policy and governance of eHealth development. eHealth strategic
planning in Europe is a complex affair involving a multitude of municipalities, regions, nations, the
EU, WHO and other strategic partners.
Enabling policies and strategies deal with the important issues of the human elements vital to
successful eHealth developments and implementation such as capacity building, interoperability
issues, multiculturalism and cultural diversity (ensuring equal access for all), and citizen protection
(security of information and equity).
eHealth applications deal with provider services, knowledge services, and public services. The
successful adoption of eHealth applications depends on the quality of foundation and enabling
policies and strategies. The range of eHealth applications is extensive. Applications that have the
greatest positive impacts should be chosen according to the utilization of scarce resources.
The discussion will continue by assessing each of these three areas in detail, specifically from the
perspective of the European Region.
Foundation policies and strategies
A significant component of the survey was dedicated to measuring progress made by countries in
establishing basic mechanisms that play a critical role in the development of eHealth at the national
level. These include establishing methods for transparent and responsive eHealth governance, strategic
policies and funding approaches supporting eHealth and promoting infrastructure development.
Governance
Governance is part of the foundation of eHealth. The need for sound governance practices has
been gaining increased recognition in recent years with the push in many countries for responsible,
participatory and equitable public-sector management. In reality, governance mechanisms are not
always established in advance of initiatives themselves. This appears to be the situation in many
countries within the European Region with respect to eHealth governance.
E P EURO Effective health care governance requires:
IN h t l a e h e r o f s n o i t a d n u o F g n i d l i u B 16 GOe Contents Summary Findings GOe Survey Discussion
References Annex
accountability of officials – they must be answerable for government decisions and actions;
participation of society (in both consultation and planning);
equitable and consistent policy and legislation relating to health; and
transparency of information on policies, regulations and decisions to all stakeholders and
the general public.
Key trends
Responding countries in the European Region have a higher average compared
to the global rate of national eHealth task forces responsible for providing advice
and guidance on eHealth issues.
The rate of eGovernance adoption for countries in the high-income group in the
European Region is also higher than that same group at the global level.
None of the responding countries from the low- or lower-middle income groups
have a national eHealth task force.
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GOe 17
To determine if countries had introduced governance mechanisms in eHealth, survey respondents were
asked if their country had a national eHealth task force or advisory board to provide advice in areas
such as policy/strategy or programme development and evaluation. In contrast to the majority of the
questions in the survey, countries were not asked to “rate the effectiveness” of these bodies or about
“future plans”, but instead to respond with “yes/no” and provide any relevant details (3). Responses can
be seen in Figure 4.
.European Region .Global
Total High Upper-middle Lower-middle Low
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Adoption (% of responding countries)
Figure 4. eHealth governance, in the European Region and globally, by World Bank income group
In many European countries, concerted efforts at governance have been under way for some years,
under the umbrella term of ‘eGovernment’. This field covers all activities relating to the use of ICT by
governments. It includes both an agency’s activities with regard to citizens, businesses and other public
agencies, as well as activities concerning internal administration processes, structures and behaviour.
One approach to eGovernment is through the provision of Web portals whereby citizens can access
government information and services including those for health. Services such as medical invoicing,
and making available patients’ laboratory results to medical institutions often leads to faster and more
personalized care. In turn, this allows citizens and organizations to use their time more efficiently – they
are no longer waiting in line for face-to-face service. Much work has been done and a lot more is
needed. The main issue for the European Region is interoperability within and between organizations
and governmental institutions. If this is not achieved, it will lead to an extra administrative barrier rather
than deliver the promise of eHealth through eGovernance.
The implementation of effective eHealth systems and services hinges on the successful collaboration
of multiple stakeholders with a diverse range of interests and agendas. It is therefore critical that
governments establish sound governance mechanisms to manage the complex process of collaboration,
which will lead to successful implementation of eHealth systems and services. The survey results indicate
that there is considerable work to be done in this area, both in the European Region and globally, as
many countries still do not have governance mechanisms in place.
See the eGovernment web site: http://webdomino1.oecd.org/COMNET/PUM/egovproweb.nsf/viewHtml/index/$FILE/glossary.htm.
(Accessed 12 February 2008.)
See eGovernment Resource centre portal at: http://www.egov.vic.gov.au/index.php?env=-categories:m1757-1-1-8-s-0&reset=1.
(Accessed 12 February 2008.)
Summary Findings Contents GOe Survey Discussion
References Annex

Policy framework
Three interrelated policy/strategy areas were surveyed, and they are listed below. For the purpose of
this report, the terms ‘policy’ and ‘strategy’ are used interchangeably; the survey questions did not ask
respondents to differentiate between whether they had introduced a policy or a strategy. The intent
was to ascertain if action had been taken in a particular area.
National information policy – a framework and approach governing a wide range of aspects
regarding national information (in digital and analogue form). Issues covered can include quality
of information, access, legal deposit, intellectual property, freedom of information, data protection
and privacy. Such policies or strategies aim to be comprehensive and cover multiple sectors.
National ePolicy – The framework required to incorporate ICT in governance is an ePolicy. It is
established by government with the intent of advancing the use of ICT. ePolicies are multisectoral
and cover the use of ICT in such areas as education, welfare, commerce, communications, health
and other sectors.
National eHealth policy – A country eHealth policy is focused specifically on achieving health
goals. In the GOe survey it referred specifically to the use of ICT in the health sector.
Key trends
The European Region has a very high rate of national information policy adoption (96%);
only one country indicated not having such a policy at the time of the survey.
The Region has a higher rate of ePolicy adoption than is the case globally for all three forms of
policy queried (national information policy, national ePolicy and national eHealth policy).
All responding countries planned to have national information policies by the year 2008
with 96% planning to have national ePolicies and 85% with plans for eHealth policies.
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18 GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E Summary Findings Contents GOe Survey Discussion
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Table 3 provides a profile of the European Region and global trends in policy adoption across the three
frameworks as well as projections for adoption levels by 2008. The results show a clear trend in policy
adoption rates; the most fully adopted being national information policies followed by national ePolicies
and eHealth policies. This trend is influenced by at least two factors. Firstly, information policies have a
broader scope than the other frameworks and are generally introduced first by governments. Secondly,
eHealth is still in its infancy in many countries, particularly developing countries, so specific eHealth
policy development is likely to be lagging behind the broader information and ePolicy frameworks.
National information policy National ePolicy National eHealth policy
2005 2008 2005 2008 2005 2008
European Region 96% 100% 88% 96% 73% 85%
Global 78% 92% 76% 90% 63% 85%
Table 3. Trends in policy adoption in the European Region and globally
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GOe 19
National information policy
Countries in the European Region have a very high rate of national information policy adoption (96%);
only one country indicated not having such a policy at the time of the global survey. Globally fewer
responding countries (78%) have such a policy currently in place.
Countries in the European Region rated their policy effectiveness generally as moderate. Only six
countries rated their policies as being very effective. All countries except one, which is undecided,
expected to continue with their national information policy. Six countries planned to revise their
policies by 2008. Figures 5–7 show the adoption of various policies in the European Region and globally,
by World Bank income grouping.
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Figure 5. National information policies in the European Region and globally, by World Bank income group
National ePolicy or strategy
A country eHealth policy is focused on achieving health goals through the use of ICT. In this survey
it refers to the use of ICT specifically in the health sector. In the European Region, 88% of responding
countries currently have an ePolicy instrument in place to promote the use of ICT across all sectors
(Figure 6). Three countries reported not having such a policy; and two of these countries planned to
introduce one over the coming years. Over half these countries rated their ePolicies as only moderately
effective; only six countries rated them as being very or extremely effective.
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Figure 6. National ePolicies in the European Region and globally, by World Bank income group
References Annex

National eHealth policy or strategy
A country eHealth policy is focused specifically on achieving health goals. In this survey it refers
specifically to the use of ICT in the health sector.
Just over 70% of responding countries in the European Region have an eHealth policy or strategy, about
10% higher than the global rate of eHealth policy adoption. Of the countries that do not, half planned
to implement one by 2008 (Figure 7). Box 1 illustrates Turkey’s road to eHealth policy adoption. Box 2
highlights steps the European Union have taken.
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Figure 7. National eHealth policies in the European Region and globally, by World Bank income group
The information regarding eHealth policy adoption based on World Bank income groups in the
European Region differs slightly from the global trend. A higher percentage of countries in the upper-middle
income groups have such a policy compared to those in the high-income group.
References Annex
Seeing the need for a more coordinated and integrated health care system, Turkey’s Ministry of Health implemented the
National Health Information System project in January 2003. Ten working groups comprising members from governmental
institutions, the private sector, nongovernmental organizations (NGOs), universities and social partners conducted inter alia
an assessment of the technological situation within their respective fields.
The eHealth Working Group, coordinated by the Ministry of Health and developed in the context of ‘eTransformation Turkey’,
has developed modules of eHealth services. The eHealth Project Proposal, prepared by the Health Transformation Programme
and eTransformation Turkey has been accepted by the International Telecommunication Union (ITU). As a further step the
eHealth Implementation Plan has been developed.
Box 1. Steps to eHealth policy adoption in Turkey

GOe 21
i2010 Subgroup on eHealth
The European Union currently includes 27 of the 53 countries in the WHO European Region. Each country is responsible,
however, for its own health care system and related policy developments. The development of eHealth policies and
strategies is challenging, and providing a common platform for policy-makers to meet, share and advance is one way to
assist Member States in this challenge.
In June of 2005, the European Commission shifted focus from the eEurope 2005 initiative to the i2010 initiative. It
launched the i2010 subgroup on eHealth, an advisory group of nominated Member States representatives, based on
the former eHealth Working Group.
The objectives of the subgroup are twofold: to develop a European eHealth service and information space that leads to improved
quality and access to care while enabling cost-effectiveness of eHealth systems and services, stimulating European industry,
and supporting European patient mobility; and to facilitate and contribute to the implementation of the European eHealth
Action Plan (by 2010) including eHealth actions plans in each of the Member States and European Economic Area countries.
The members of the subgroup include decision-makers and leaders in the definition and implementation of national eHealth
initiatives in each Member State. They are complemented by stakeholders in national Telecommunications ministries. Other
complementary organizations involved include health authority associations, industrial associations, health professional
representatives, and user groups involving patients and citizens – represented in an associated eHealth Stakeholders’ Group.
In 2006, the second year of activity, all Member States prepared their eHealth strategies and action plans, often closely linked
with the development of relevant information societies within countries. These plans are being developed and implemented
in different organizational health, medical and telecommunications contexts, which often include close partnerships between
the public and private sector. By the end of 2006, a compilation was made of all the available Member States’ plans and
roadmaps, the good practice in the development of country’s eHealth action plans, and in the field of eHealth more generally.
Source: Adapted, with permission, from:
http://ec.europa.eu/information_society/activities/health/policy_action_plan/i2010subgroup/index_en.htm#Background_history
Box 2. Supporting policy-makers in building eHealth Policies: eHealth in the European Union
Conclusion
These three policy areas set the foundations for appropriate development and handling of data and
information, in particular, digital information. These policies are multisectoral and usually contain
components relative (although not specific) to the health sector. As eHealth policies are the most
specialized within this framework they generally follow the introduction of the broader policies.
Examples from Turkey and the European Union illustrate the point that most governments now see
the need to shape the development and management of the eHealth domain through eHealth policies,
which make transparent the regulations and laws related to data and information in the health sector.
Compared to other WHO regions, the European Region has a relatively high adoption rate of eHealth
policies enabled partly through the facilitation of the European Commission and related eHealth Action
plan (6). However there still remains a need for substantial policy action, particularly in the countries
from the lower-middle and low-income groups.
To support Member States in their efforts to shape eHealth policy, the Global Observatory for eHealth
will establish a thematic working group to develop a set of tools and guidelines for adaptation by
countries on proven practice in eHealth policy development and evaluation.
References Annex

Funding approaches
Critical to foundation actions in national eHealth capability is the development of a funding framework
to support the national eHealth vision. An adequate funding environment is important in ensuring that
eHealth policies and action plans can be carried out in a sustainable way.
The following approaches to funding were explored in the survey:
Public funding – providing ongoing public funding for ICT support of programmes addressing
national health priorities.
Private funding – securing private funding, through grants or private investments, for ICT support
of programmes addressing national health priorities.
Public-private partnerships – partnerships formed between public organizations and private
entities to foster the use of ICT in the health sector.
Procurement policy – guidelines and procedures developed by institutions or governments to
guide software, hardware and content acquisition in the health sector.
Key trends
Public funding in this Region remains the primary means of support for eHealth activities
(81%). This is a higher level than the global average (68%).
The European Region reported the highest adoption of policies related to securing private
funding through grants or private investment for ICT support to programmes addressing
national health priorities (50%) compared to other regions.
The European Region lags behind the global average in terms of forming public-private
partnerships to foster the use of ICT within the health sector.
Over half of the responding countries in the Region (54%) indicated that procurement
policies are in place.
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EURO IN Public funding Private funding Public-private
h t l a e h e r o f s n o i t a d n u o F g n i d l i u B 22 GOe Contents Summary Findings GOe Survey Discussion
References Annex
partnerships Procurement policy
2005 2008 2005 2008 2005 2008 2005 2008
European Region 81% 91% 50% 58% 42% 52% 54% 73%
Global 68% 79% 37% 49% 54% 60% 50% 79%
Table 4. Trends in funding approaches in the European Region and globally
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GOe 23
Public funding for ICT support
Public funding remains the primary means of support for eHealth activities with 81% of responding
countries in the European Region providing ongoing public funding for ICT support to programmes
that address national health priorities (see Figure 8). The few countries that do not benefit from public
funding for ICT support cut across the three World Bank income groups represented in the survey.
The majority of countries (62%) rated their public funding programmes moderately effective or better.
Three countries consider their public funding to be only slightly effective, one country has an unknown
rating, and five countries did not respond to this question.
Of the four countries that do not have public funding mechanisms in place, two indicated that they
would introduce them by 2008 and the other two were undecided.
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Figure 8. Public funding mechanisms in the European Region and globally, by World Bank income group
Private funding
Compared to all other WHO regions, responding countries from the European Region reported the highest
adoption rate (50%) of securing private funding (through grants or private investment) for ICT support
to programmes addressing national health priorities. Of these, five countries rated their private funding
approach to be very effective. Three countries rated it as moderately effective, three as only slightly
effective and two countries did not know. Of those countries that do have a private funding mechanism in
place, two countries were undecided as to whether to continue with this approach or not.
Within World Bank income groups for the Region, the highest proportion of private funding is found
among the lower-middle income group (67% – Figure 9). This is the opposite of the global trend, which
shows this group having the lowest rate of private funding (28%). The lower-middle income groups
are likely to have received substantial funding from development banks and agencies as well as the
European Union, which could account for increased private funding sources.
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Figure 9. Private funding in the European Region and globally, by World Bank income group
References Annex

Public-private partnerships
eHealth is well suited to public-private partnerships (7). As the ICT industry is primarily driven by the private
sector, the industry can offer significant value including technical expertise, equipment, training, project
management and financial support to any partnerships involving the technology required for eHealth.
Eleven countries (42%) within the European Region reported having established public-private
partnerships (Figure 10). This is lower than the global average (54%). Over half of these countries
view their partnerships as very or extremely effective. Three countries reported their programmes
moderately effective. One country reported it to be only slightly effective and one country did not
know the effectiveness of this partnership.
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Figure 10. Public-private partnerships in the European Region and globally, by World Bank income group
24 GOe B u i l d i n g F o u n d a t i o n s f o r e h e a l t h IN EURO P E Summary Findings Contents GOe Survey Discussion References Annex

GOe 25
Procurement policies
Procurement policies can influence costs dramatically as they influence how resources are allocated
for eHealth systems and services over time. They affect resource allocation, purchasing and business
processes at all levels. Only slightly more than half the countries (54%) reported having a procurement
policy in place to guide software, hardware and content acquisition in the health sector. This is nearly
the same as the global average of 50%.
A low potential purchasing power of ICT goods and services (such as evidenced by countries in the
lower-income group) is in fact the best reason for developing a sound procurement mechanism. With
such procurement policies, the purchasing power of these countries could rise. Relying too heavily on
donor supply of ICT reduces the ability (and interest) of countries to develop their own ICT. The dramatic
projected growth in procurement policies globally attests to the fact that the financial importance of a
sound procurement policy is becoming recognized.
Of the countries that responded, fourteen (54%) had a procurement policy in place (Figure 11). Seven
countries rated them as very or extremely effective, five rated them as moderately effective, one
as only slightly effective; and one stated that the policy’s effectiveness is unknown. Five countries
indicated that they would start a procurement policy by 2008 and five countries were undecided in
their future course of action.
Among the countries reporting from the Region, there are higher rates of those from the upper-middle
and lower-middle income groups with procurement policies in place than the trend found globally.
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Figure 11. Procurement policies in the European Region and globally, by World Bank income group
Conclusion
Public funding continues to be by far the most common source of financing for ICT in the health sector
in the European Region. Evidence-based project successes and examples of best practices in this area
should be articulated and encouraged.
The importance of public-private partnerships is clearly beginning to be recognized. However, care
needs to be taken with these partnerships to ensure the social good. Legal agreements are required to
clearly lay out expectations and obligations for both sides of the partnership.
The Global Observatory for eHealth will develop a worldwide database of eHealth proven practices to
help promote public-private partnerships and support the process of eHealth initiatives’ application for
funding from both governments and donors.
References Annex

Infrastructure
Infrastructure refers to the connectivity, the hardware and software required to deliver and process
digital content. As eHealth systems and services cannot exist without a technical infrastructure for
their creation and delivery, it has been classified as one of the key foundation actions in the eHealth
Development Model.
Three complementary measures were surveyed to ascertain national approaches used to build
infrastructure for the health sector to support the development of eHealth systems and services.
Intersectoral and nongovernmental cooperation – Working with NGOs and other sectors, such
as the businesses, aid agencies or other bodies, to promote infrastructure development.
National ICT in health development plan – A plan or ‘roadmap’ for the national deployment and
development of ICT infrastructure, services and systems in the health sector.
Affordability policy – Implementing a national policy to reduce the costs of ICT infrastructure for
the health sector, for example of computer equipment, software, Internet or communications.
Using these three categories as a guide, the following discussion will highlight the state of infrastructure
development in the European Region. Table 5 shows the overall trends in the Region, as well as globally.
Key trends
The European Region is on par in intersectoral and NGO cooperation adoption with
the global average. This is not expected to grow (unlike in much of the developing
world) as countries in the Region tend to cooperate more with the private sector,
rather than rely on NGOs for example.
The European Region has a slightly lower rate of national eHealth ICT planning than
globally among countries in the high- and upper-middle income brackets. Adoption is
slightly higher among countries in the lower-middle income group.
The European Region also has a lower than average rate of adoption of affordability policies
among countries in the high-income group. This trend is opposite, however, in countries in
the upper-middle income group.
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h e r o f s n o i t a d n u o F g n i d l i u B 26 GOe Contents Summary Findings GOe Survey Discussion
References Annex
Affordability policy
2005 2008 2005 2008 2005 2008
European Region 77% 77% 60% 80% 29% 58%
Global 72% 80% 56% 80% 36% 62%
Table 5. Trends in approaches to infrastructure development in the European Region and globally
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GOe 27
Intersectoral and nongovernmental cooperation
Intersectoral and nongovernmental cooperation within the European Region is quite high (77%).
Globally, it is the most widespread approach for building infrastructure for eHealth (Table 5). Unlike
much of the developing world, this type of cooperation in the European Region tends to be with the
private sector rather than NGOs and aid agencies.
The data by World Bank income group shows that cooperation is generally a little higher than the global
averages except for the lower-middle income group, where it is slightly lower (Figure 12).
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Figure 12. Intersectoral and nongovernmental cooperation for infrastructure development
in the European Region and globally, by World Bank income group
National plan for the development of ICT in health
A national ICT for health development plan is a relatively new and important approach for eHealth
development. Historically eHealth has simply emerged in conjunction with technology rather than
been planned to evolve with it. The European Region generally has a slightly lower rate of national
planning in the upper- and upper-middle income groups compared to the global trend, and is slightly
higher than the global average in the lower-middle income level (Figure 13).
Development plan ‘roadmaps’ are rapidly gaining recognition and acceptance as an integral part of the
process of infrastructure building. This is reflected in the substantial rise from a current adoption rate
of 60% to an expected rate of 80% by 2008 (Table 5). This represents a commitment to sound design
of systems, and establishment of eHealth infrastructural integration, which is vital for cost savings,
standardization and portability of information flows.
Adoption (% of responding countries) Figure 13. National plan for the development of ICT in health in the European
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Region and globally, by World Bank income group
References Annex

Affordability policy
An affordability policy aims to reduce and control the costs of ICT Infrastructure. Currently such policies
have a low rate of adoption globally, but substantial growth is expected by 2008. This may be explained
by the fact that affordability policies are comparatively new and not yet well tested, but their perceived
value is increasing. If developed and administered correctly they contribute towards maximizing savings
on purchases, which in turn results in stretching the buying power of fixed budgets.
Despite the value of such a policy, only eight countries responding from the European Region (35%)
reported having an affordability policy. Moreover, only four of these countries rated their policies as very
effective or better; the rest found them to be only moderately to slightly effective. The adoption of such
policies is shown in Figure 14. The data show however that the European Region plans to improve the
rate of adoption of affordability policies to almost 60% by 2008. This shows an increasing awareness on
the part of countries of the need to maximize ICT budgets for health care.
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Figure 14. Affordability policy in the European Region and globally, by World Bank income group
Conclusion
Implementation of national plans for the development of ICT in health and the introduction of
affordability policies are two actions within the area of infrastructure development that hold the
promise of significant growth in the future.
National plans for ICT development in health represent a sound approach to the systematic design,
establishment and integration of infrastructure for eHealth. Member States forecast a great deal of growth in
this area – recognition by governments of its benefits. The adoption of affordability policies for infrastructure
is expected to increase even more as governments begin to realize financial and technical gains.

GOe 29
Enabling policies and strategies
Enabling policies and strategies that facilitate eHealth developments are the bridges between foundation
actions such as good (eHealth) governance, developing a sound policy framework, funding and
infrastructure and the provision of effective and responsive eHealth services. These strategies focus on the
protection of citizen data and confidentiality, promote equity of access throughout society, and promote
multilingualism and cultural diversity in cyberspace. They also facilitate the development of eHealth
standards to ensure diverse systems can communicate with each other, and build human resources
capacity so that health professionals are well trained in the use of the many eHealth applications.
Citizen protection
The newness of eHealth and the potential for its establishment into health care systems leaves many people
uneasy about the privacy and confidentiality of their personal health information. Media reports of high
profile computer security breaches in the corporate world undermine public confidence in the security of
their private health records through misuse by parties which have illegally gained access to them.
Governments and health-care organizations will invest billions of euros in eHealth systems in the years
ahead. There are numerous eHealth systems vendors manufacturing and selling electronic health record
(EHR) systems, hospital information systems (HIS) and medical devices, not to mention the numerous
networking and communications software and hardware providers. Though each of these vendors is
committed to delivering secure solutions it is critical that every effort be made to ensure the integrity
and confidentiality of these applications, through, for example, legislation.
Key trends
The European Region reported the highest rate of implementing citizen protection policies
and strategies (77%) relative to the other WHO regions across the globe.
The rate of implementing standards, regulations or legislation to protect the privacy and
security of patient data is relatively high for countries in the high- and upper-middle
income groups, but very low for those in the lower-middle income group.
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Table 6 shows the growth in citizen protection policies from 2005 to 2008. Of the responding countries
in the European Region, twenty have taken action, nine of which indicated that their systems were very
or extremely effective. Seven countries thought them moderately effective, and two found them to be
only slightly effective. A further two countries did not know their effectiveness.
Policies to protect patient data
2005 2008
European Region 75% 88%
Global 51% 78%
Table 6. Trends in adoption of citizen protection policies in the European Region and globally
References Annex
p

Figure 15 shows the adoption of policies on data protection, on the part of countries in the European
Region as well as globally. The trend shows that the poorer the country, the less likely the country will
have a policy on data protection. Boxes 3 and 4 illustrate the experiences from the European Union and
the United Kingdom of Great Britain and Northern Ireland.
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Figure 15. Policies to protect patient data in the European Region and globally, by World Bank income group
Ensuring the security of information is a challenge for both users and suppliers. Lack of confidence in existing solutions has
hindered implementation of health informatics applications and the effective use of the Internet.*
The ‘always-on’ feature of broadband can increase the vulnerability of networks and of the information transmitted on them.
Fully interactive applications, needed for public services, require an adequate level of confidence in areas such as identity
management, e-payment and patients’ rights.
The main eHealth security threats are summarized as follows:
References Annex
unauthorized access to and modification of (confidential) information;
incorrect identification of the source/origin of medical information transmitted via the Internet;
loss of data and exposure of personal information;
alteration of medical records, even by authorized medical personnel and/or institutions (e.g. for remote
diagnostics and medical advice);
insufficient security (encryption) of transmitted health information between medical institutions; and
an insecure communications and processing infrastructure (i.e. vulnerable to hackers).
The eEurope 2005 Action Plan** of the European Commission recommends action on security by introducing policies
for improving networks and information systems, e-Authentication through smart cards, privacy directives, citizens’
rights, international trade, industrial policy and law enforcement. Through the electronic signatures directive and the
data protection legislation for electronic communication, *** the EU aims to reduce security and privacy concerns for a
wide range of services and to ensure accurate operations.
* Gross, G. (2005) Lack of standards hinders electronic health records, IDG News Service, 10 January 2005, URL: http://www.itworld.com/Tech/2987/
050110healthstandards/, accessed 11 January 2005
** Commission of the European Communities (2002), eEurope 2005: An information society for all, COM (2002) 263 final, Brussels: CEC, URL: http://europa.
eu.int/eur-lex/lex/LexUriServ/site/en/com/2002/com2002_0263en01.pdf, accessed 10 November 2004
*** European Parliament & European Council (1999), Directive 1999/93/EC of the European Parliament and of the Council of 13 December 1999 on a
Community framework for electronic signatures, Official Journal of the European Communities, Brussels, URL: http://europa.eu.int/eur-lex/pri/en/oj/
dat/2000/l_013/l_01320000119en00120020.pdf, accessed 13 December 2004.
Box 3. Challenges of information security, and measures to protect citizens in the European Union
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GOe 31
One of the most significant challenges in the United Kingdom has been securing public and professional confidence
in the information governance arrangements and privacy and confidentiality measures around holding and processing
sensitive health information electronically.
This has been dealt with through extensive consultation with the public and health professionals, and maintaining transparent
policies regarding the use of health data. A framework for information governance has been established, developed in full
consultation with health-care professionals (arising out of the Caldicott review, all National Health Service bodies have senior
clinicians appointed to oversee the confidentiality of patient data). The national programme for ICT infrastructure is being
implemented with rigorous security measures including the use of smart cards for health-care professionals and mechanisms
for patients to define what information they wish to be shared, and under what circumstances.
Box 4. Protecting the citizen’s information: the approach taken by the United Kingdom
Equity
Equity is recognized as a core value of health development. It is determined by policies to promote
inclusive and equitable access to eHealth services to all groups within a nation. Within and between
countries inequalities exist. The digital divide refers to inequalities in access to, and use of information
and communication technologies. It can result from many factors such as geography, economics, age,
gender, education, ICT skills and language (2). Human, ethical, and legal rights issues are also involved,
in particular the right to the highest attainable standard of health. Efforts are needed to tackle the
undue burden of ill-health borne by vulnerable and marginalized groups. This involves investment in
development of infrastructure for ICT for health.
Key trends
The adoption of equity policies in the European Region is slightly higher than
the global average.
Of those countries which have established equity policies, the majority consider
them to be extremely to moderately effective.
This is expected to grow to grow to almost 70% of responding countries by 2008.
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References Annex

The findings from the survey indicate that equity issues for eHealth have yet to be adequately addressed.
The rate of adoption of equity policies is considerably lower than that of citizen protection. Within
the European Region 52% of responding countries implemented policies to promote inclusiveness
and equitable access to eHealth irrespective of culture, education, language, geographical location,
physical and mental ability, age and gender (Table 7). Figure 16 shows the trends in policy adoption in
the European Region and globally.
Policies to promote equitable access to eHealth
2005 2008
European Region 52% 78%
Global 44% 78%
Table 7. Trends in adoption of equity policies in the European Region and globally
100
90
80
70
60
50
40
30
20
10
0
Figure 16. Policies to promote equitable access to eHealth in the European
References Annex
Region and globally, by World Bank income group
Fifteen of the responding countries in the European Region have implemented an equity policy. Of
those countries, seven rated them as very to extremely effective, four as moderately effective, one
as only slightly effective, and three asserted that the effectiveness of their policies at this stage were
unknown. By 2008 six countries planned to revise their policies, four countries planned to implement an
equity policy for the first time, and seven countries had not decided on a course of action.
Conclusion
Though the European Region shows a much higher rate of adoption of citizen protection policies than
is the case globally, much more work in this area is needed in the lower-middle income countries, where
a low adoption rate for citizen data and information protection mechanisms may leave these countries
vulnerable to security breaches.
One of the promises made by eHealth is to make health care more equitable, but there is a considerable
threat that eHealth will actually deepen the digital divide. People who do not have resources and
technological skills cannot access technology effectively. As a result, these ‘have-not’ populations – who
would have the most to gain from eHealth – are those who are the least likely to benefit from advances
in ICT. Political will and effective implementation of policies, therefore, are required to fulfil the promise
of equitable access for all.

GOe 33
Multilingualism and cultural diversity
Multilingualism and cultural diversity refers to the respect for, and promotion of linguistic diversity,
cultural identity, traditions and religions within cultures.10
Language is the most direct expression of culture; it is what makes us human and what gives each of us
a sense of identity (8). The EU Charter of Human Rights prohibits discrimination based on a number of
grounds, including language.
Multilingualism refers to both a person’s ability to use several languages and the co-existence of different
language communities in one geographical area. Policies in this area promote a society that respects all
citizens’ linguistic identities and well-being.
Three complementary multilingualism and cultural diversity actions were assessed:
Policies on multilingualism and cultural diversity – implementing policies or strategies that
promote both the availability of information in local languages and that recognize cultural
diversity.
Multilingual projects – introducing special projects to promote the development and use of new
electronic health content in multiple languages.
Translation and cultural adaptation – supporting the translation and cultural adaptation
(localization) of existing high-quality content created either locally or abroad.
Key trends
The European Region is slightly lower than the global average with regard to having
policies to promote the creation of multilingual health content. Even among high-income
countries implementation of such policies is low.
Introducing special projects to promote the development and use of new electronic
content in multiple languages is less prevalent in Europe than globally.
Ten responding countries in Europe (41%) support the translation and cultural adaptation
(localization) of existing high-quality content. This is above the global average.
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Table 8 shows that not only have relatively few of the responding countries developed multilingual/
multicultural policies, but they do not appear to be having the desired outcome of stimulating the
development of multilingual health content. This means that many citizens may be unable to access
eHealth resources due to language barriers.
Multilingualism and cultural
diversity policy
Multilingual projects Translation and cultural
adaptation
2005 2008 2005 2008 2005 2008
European Region 42% 52% 32% 47% 41% 46%
Global 50% 62% 22% 36% 31% 42%
Table 8. Trends in multilingual policies and projects in the European Region and globally
10 From Glossary at: http://www.who.int/goe/data/Global_eHealth_Survey-Glossary-ENGLISH.pdf.
References Annex
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Only 42% of the responding countries in the Region had adopted policies in 2005 (Table 8). In late
2005, the European Commission introduced a strategy to promote multilingualism, which should help
to address the lack of such policies in countries within the European Union (8). One of the aims of the
strategy is to encourage language learning and promoting linguistic diversity in society. While countries
in the European Region projected an incremental growth over the next few years, this is likely to increase
once the EU multilingualism strategy takes effect.
Of the twelve countries that have implemented multilingualism and cultural diversity policies, four
rated them as very effective, three rated them moderately effective, three as only slightly effective, and
two did not know the effectiveness of these policies.
A large proportion of countries (10) in the Region are undecided as to their future direction in this
domain. Two countries responded to the survey they would adopt such a policy by 2008, and five
planned to revise their current policies.
With regard to the World Bank income groupings, a trend in the European Region becomes
apparent: there is a relationship between World Bank income groups and the likelihood of countries
having introduced these policies. That is, the higher the income group, the more likely it is that a
country will have a multilingual policy in place. Figure 17 shows the adoption of multilingualism
policies in the European Region.
100
90
80
70
60
50
40
30
20
E P 10
0
EURO Total High Upper-middle Lower-middle Low
IN h t l a e h e r o f s n o i t a d n u o F g n i d l i u B 34 GOe Contents Summary Findings GOe Survey Discussion
References Annex
Figure 17. Policies to promote the creation of multilingual eHealth content in
the European Region and globally, by World Bank income group

GOe 35
Multilingual projects
The introduction of special projects to promote the development and use of new eHealth content in
multiple languages is the definition of multilingual projects, and was the second query in the survey.
Unlike the scenario of policy development described previously, which is less resource intensive,
developing original multicultural health content is labour intensive, requires specialist skills and is
expensive, thus limiting some countries’ activities in this field. Figure 18 shows data for this indicator. An
example of providing online access to health content in multiple languages is shown in Box 5.
Due to its labour-intensive nature, only eight countries in the Region have introduced special projects
to promote the development and use of new health content in multiple languages. Three countries
rated their projects as very effective, two as moderately effective and one as only slightly effective. Two
countries were unable to rate their projects’ effectiveness.
In the short-term (by 2008) six countries planned to continue with their projects, two planned to
revise theirs before continuing, three planned to start such projects and a large number of countries
(13) were undecided on this question.
The European Region ranks lower than the global figures for introducing projects to promote the
development and use of new eHealth content in multiple languages.
100
90
80
70
60
50
40
30
20
10
0
Figure 18. Multilingual eHealth content in the European Region and globally, by World Bank income group
While NHS Direct Online is an English-language site, NHS Direct and local NHS organizations provide translation facilities for
patients with specific queries. This has been found to be the most cost-effective approach, and which allows resources to be
deployed most effectively.
NHS Direct Online, on behalf of the Department of Health, is developing a Patient Information Bank of quality assured,
evidence-based, health information leaflets which NHS staff can print and give to patients. The bank contains over 100
patient information leaflets and fact sheets. They cover common health conditions such as back pain, heart attack and
influenza, procedures such as X-rays, and public health advice on sexually transmitted infections (STIs) and healthy eating
habits. These leaflets have been developed using information drawn from the NHS Direct Online web site (www.nhsdirect.
nhs.uk), and are available in 12 languages besides English: Arabic, Bengali, French, Gujariti, Korean, Polish, Portuguese,
Punjabi, Somali, Spanish, Turkish and Urdu.
Source: Global eHealth Survey 2005 (WHO/GOe).
Box 5. NHS Direct Online multilingual content
References Annex

Translation and cultural adaptation
The third query, about translation and cultural adaptation of content, is the process of translating
and adapting information products to suit the language and cultural needs of groups, populations
or countries. This process may be easier and faster than producing original content; specialist skills,
however, are still required for translations and multicultural adaptation. In the European Region, this
approach is less utilized than the development of original content. This is in contrast to the global trend,
which shows a marginally higher adoption of translation and adaptation of content.
Ten countries in the European Region (41%) supported the translation and cultural adaptation
(localization) of existing high-quality content (created either locally or abroad) (Table 8).
Only two countries rated this approach as very effective; four countries rated it moderately effective,
two only slightly effective and two did not know. Despite not rating them very effective, three of five
responding countries planned to continue with this approach; three others planned to make revisions;
and only one country planned to start such a programme by 2008. The majority of responses (13) were
undecided (or did not respond to this question). These data would suggest there is a lack of a consensus
on this issue in the European Region.
There appears to be no clear relationship between World Bank income group and this action. Countries in
the high-income group in the European Region rank lower than those globally in supporting localization
of existing high-quality content, but those in the upper-middle income bracket rank higher (Figure 19).
100
90
80
70
60
50
40
30
E P 20
10
EURO 0
IN World Bank income group
h t l a e h e r o f s n o i t a d n u o F g n i d l i u B 36 GOe Contents Summary Findings GOe Survey Discussion
References Annex
Figure 19. Translation and cultural adaptation of eHealth content in the
European Region and globally, by World Bank income group
Conclusion
Multilingualism and cultural diversity is the least developed area of any examined in the survey. Not only
do less than half of responding countries across the European Region have multilingual/multicultural
policies, but the projected figures indicate limited growth. This is an area where the translation of policy
into action seems problematic.
These issues, which directly affect citizen access to information, are not high on the current agenda of
many governments. If this trend continues, many citizens may continue to be excluded from eHealth
services due to language barriers. The lack of access to digital information by cultural and ethnic groups
within nations contributes directly to fragmentation and inequality of access to resources, enhancing
the digital divide within countries.

GOe 37
Interoperability
Interoperability is used to describe systems and services that are connected and can work together seamlessly
and effectively, while maintaining patient and professional confidentiality, privacy and security (9).
Interoperability of health systems and services is a major challenge for individual Member States and
for health sector actors. It has the potential, however, to help resolve a number of pressing issues facing
Europe’s health-care systems and services, namely those of integrated services where information must
flow through all levels of the health system.
It requires concerted action (cooperation) and coordination at various levels to be successful, ranging
from the local to the global, with an important component coming from technical experts. Examples
include the exchange of messages between various health-care facilities and their numerous
applications; electronic health records (EHRs); patient identifiers; coding terminology; clinical guidelines
and documentation; and business processes of health care institutions.11
As the term implies, interoperability is involved in all aspects of eHealth.12 Standards are the spine of
interoperability, and the development of common standards requires input and collaboration from
both the technical and political points of view.13
Standards allow for interoperability between health system operations within an institution, a region, a
country and internationally. The greater the standardization, the greater the freedom of choice a user
has when working within a particular system.
Additionally, standards have a strong impact on eHealth financing. When governments establish
standards, the transaction costs between systems drop considerably, therefore the process of
transferring data and information between systems becomes more economical.
For the purpose of this survey, eHealth standards were defined as technical specifications developed by
multiple stakeholders through a consensus approach to promote interoperability among systems for
the deployment of eHealth applications (3).
Key trends
The European Region has a high overall number of countries adopting norms and standards
for eHealth systems, services or applications.
Countries in the high- and upper-middle income groups appear more likely to adopt
eHealth standards than lower-middle countries.
It appears that by 2008 all responding countries will have adopted standards for eHealth.
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11 More information can be found at: http://www.srdc.metu.edu.tr/webpage/projects/ride/publications/DogacMalaga-eHealthPaperApril14.
doc ; and http://www.srdc.metu.edu.tr/webpage/projects/ride/.
12 Also see: http://www.esa.int/telemedicine-alliance.
13 For an annotated list of significant standards see: http://www.who.int/ehscg/resources/en/ehscg_standards_list.pdf.
References Annex

Figure 20 shows the European Region’s adoption of eHealth standards by World Bank income group and
the global figures for comparison. The uptake of such standards in the European Region is much more
advanced than the global average. All responding countries predicted they would have implemented
policies on standards by 2008.
100
90
80
70
60
50
40
30
20
10
0
Figure 20. eHealth standards in the European Region and globally, by World Bank income group
Twenty-one countries in the European Region have adopted norms and standards for eHealth systems,
services or applications. Eighteen rated their standardization as moderately to extremely effective, one
as only slightly effective, and two were undecided. Five countries did not respond to this question.
Thirteen countries planned to continue without change over the next two years, nine planned to revise
their policies, and four planned to introduce standards by 2008.
To foster an environment of cooperation on eHealth interoperability, WHO has built partnerships with
ITU, the European Commission and the European Space Agency, as well as individual Member States.
The Telemedicine Alliance14 has drawn up strategic recommendations for interoperability of eHealth
applications across the countries of Europe (see Box 6) (10), 15. Box 7 shows an example from Norway.
E P EURO IN h t l a e h e r o f s n o i t a d n u o F g n i d l i u 14 http://www.esa.int/esaMI/Telemedicine_Alliance/index.html.
B 15 See also: http://ec.europa.eu/information_society/activities/health/docs/projects/fp6book/tma-bridge.pdf.
38 GOe Contents Summary Findings GOe Survey Discussion
References Annex

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